Healthcare Provider Details

I. General information

NPI: 1710646344
Provider Name (Legal Business Name): CHEYENNE REGIONAL PHYSICIANS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOUSE AVE STE 201
CHEYENNE WY
82001-3177
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-7757
  • Fax: 307-638-8359
Mailing address:
  • Phone: 307-638-7757
  • Fax: 307-638-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRAD WHITE
Title or Position: ADMINISTRATOR OF REVENUE
Credential:
Phone: 307-633-6198